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Lumbar disc herniation

119 citationsUpdated Sep 2026

Overview

Lumbar disc herniation arises from a degenerative process where genetic factors are increasingly recognized as more significant than mechanical stress [19]. While the overall incidence of regression in non-surgically treated patients is 63% [2], most herniations remain stable over a four- to eight-year period [4]. The condition may present as radiculopathy or as discogenic pain associated with internal disc derangement (IDD), a pathologic condition causing axial spine pain without significant deformity or instability [19]. IDD typically affects patients in their third to sixth decades, presenting with chronic axial and sclerotomal pain that exacerbates with flexion and improves with recumbency [19]. Diagnosis requires the exclusion of other pathologies, as there are no pathognomonic findings or defined criteria for IDD [19].

Surgical outcomes for open disc surgery vary widely, with good results ranging from 46% to 97% and reoperation rates from 4% to over 20% [80]. No specific discectomy technique yields consistently superior results; rather, patient selection is crucial, with factors such as low educational level, MMPI scores, and compensation status significantly affecting outcomes [80]. The SPORT trial demonstrated that operative treatment resulted in less pain and better function than nonoperative care, though its validity has been questioned due to high crossover rates [80]. Complications are generally low, with wound infection occurring in 2.2% of cases, dural tears in 1.6%, and cauda equina syndrome in 0.2% [80]. Recurrent herniation is the most common complication following primary diskectomy, defined by recurrent pain after a pain-free period of at least six months [15].

Special populations, including professional athletes and adolescents, generally show favorable prognoses, with 82% of athletes returning to play [6]. Age is not a contraindication for decompressive surgery [65], and endoscopic techniques remain effective in obese patients [63]. Biportal endoscopic discectomy offers distinct advantages in reducing wound complications compared to microscopic discectomy [5]. While the "6 mm rule" for herniation size is not supported [26], lumbar total disc replacement may be considered for patients with herniated nucleus pulposus and radiculopathy [72]. Further research is needed to identify patients who will fail nonoperative treatment and benefit from early discectomy [38].

Anatomy & Pathophysiology

Disc Structure and Composition

The intervertebral disc comprises a central gelatinous nucleus pulposus (NP) surrounded by a fibrous annulus fibrosus (AF) [101]. The NP consists primarily of high concentrations of proteoglycans and water within a loose type II collagen network with random fibril orientation [101]. In contrast, the AF exhibits low proteoglycan and water content, high type I collagen concentration, and is organized into 20 to 25 concentric lamellae [101]. Within the AF, collagen fibrils in adjacent lamellae are oriented in opposite directions to resist tensile forces during bending and twisting [101]. Disc composition varies with age, characterized by decreasing proteoglycan and water content in the NP as age increases [101]. Epidemiologically, the incidence of disc herniation ranges between 5 and 20 cases per 1000 adults, with a male predominance averaging 41 years old [201]. Approximately 95% of herniated discs are located in the lower lumbar spine, with the greatest prevalence among those aged 30 to 50 years [201].

Neural Anatomy and Innervation

In the lumbar spine, the named nerve root exits below the named pedicle [95]. Consequently, lateral recess pathology, such as posterolateral disc herniation, typically involves the next nerve root exiting caudal to that disc [95]. For instance, an L4-5 posterolateral disc herniation is expected to cause L5 nerve root symptoms [95]. The dorsal root ganglion (DRG) lies within the outer confines of the intervertebral foramen [95]. The sinuvertebral nerve, a recurrent branch of the ventral ramus, innervates the posterior aspect of the disc and vertebral bodies [95]. Disc innervation involves afferent axons with cell bodies within the DRG, transmitting nociceptive signals to the spinal cord [95]. Animal studies reveal two paths between the annulus and the DRG: one from the sinuvertebral nerve and another along the paravertebral sympathetic trunk [95]. The lateral annulus is innervated by fibers from the index level and two additional superior levels through sinuvertebral nerves, as well as by DRG fibers from three levels more superior via the sympathetic trunk [95]. Contralateral DRG involvement occurs through both sinuvertebral and sympathetic pathways [95]. The vertebral endplate is innervated by the basivertebral nerve, which enters the vertebral margin with vessels [95]. The density of innervation at the vertebral endplate is similar to that of the outer annulus, suggesting endplates are as important to pain generation as the annulus [95]. The medial branch of the dorsal ramus provides primary innervation to the facet joints at that level and adjacent levels above and below [95].

Degenerative Pathophysiology

Lumbar disc herniation results from underlying disc degeneration [128]. Acute disc herniation occurs most commonly in the fourth to fifth decades of life and is more common in men than women with a 3:1 ratio [128]. Herniation occurs mostly at the L4/5 and L5/S1 disc levels [128]. Morphologically, a protrusion is defined as a posteriorly bulging disc with the outer annulus intact [128]. A rupture occurs when fibrocartilaginous disc material is extruded posteriorly through the posterior longitudinal ligament [128]. Sequestration is defined as disc material breaking free to lie in the canal [128]. A posterolateral rupture presses on the nerve root proximal to its point of exit through the intervertebral foramen [128]. Specifically, a herniation at L4/5 compresses the fifth lumbar nerve root, and a herniation at L5/S1 compresses the first sacral root [128]. Acute back pain at the onset of disc herniation arises from disruption of the outermost layers of the annulus fibrosus and stretching or tearing of the posterior longitudinal ligament [128]. Nerve root irritation causes pain in the buttock that may radiate down the posterior thigh and calf [128]. Pressure on the nerve root causes paresthesia, numbness, weakness, and depressed reflexes in the corresponding dermatome and muscles [128].

The degenerative process is divided into three stages: dysfunction (ages 15–45), instability (ages 35–70), and stabilization (age >60) [23]. The dysfunction stage is characterized by circumferential and radial tears in the disc annulus and localized synovitis of the facet joints [23]. The instability stage is characterized by internal disruption of the disc, progressive disc resorption, facet joint degeneration with capsular laxity, subluxation, and joint erosion [23]. The stabilization stage is characterized by progressive development of hypertrophic bone around the disc and facet joints leading to segmental stiffening or ankylosis [23]. Disc herniation is considered a complication of disc degeneration in the dysfunction and instability stages [23]. Spinal stenosis from degenerative arthritis is a complication of bony overgrowth compromising neural tissue in the late instability and early stabilization stages [23]. Each spinal segment degenerates at a different rate, such that one level may be in the dysfunction stage while another is entering the stabilization stage [23].

Genetic factors are more important than mechanical stresses in the development of disc herniation [19]. The development of a disc herniation is one of several pathways that a degenerative disc may follow [19]. Internal disc derangement (IDD) is defined as a pathologic condition resulting in axial spine pain with no or minimal deformation of spinal alignment or disc contour [19]. IDD is distinguished from measurable instability caused by fractures, traumatic ligamentous disruptions, degenerative listhesis, or scoliosis [19]. The natural history of degenerative disc disease involves recurrent episodes of pain followed by periods of significant or complete relief [27]. Generally symptomatic lumbar disc herniation has a favorable outcome in most patients [27]. The primary benefit of surgery for lumbar disc herniation occurs early in the first year, with statistical significance of improvement lost over time [27]. Nonprogressive neurologic deficits originating from the lumbar spine, except cauda equina syndrome, can be treated nonoperatively with expected clinical improvement [27]. Surgery for nonprogressive neurologic deficits can usually be delayed 6 to 12 weeks to allow opportunity for improvement [27].

Lumbar disc herniation is among the most common causes of lower-back pain and sciatica [18]. The cause of lumbar disc herniation comprises a complex combination of mechanical and biologic processes [18]. The natural history of lumbar disc herniation is generally favorable [18]. Low back pain is a leading cause of disability worldwide, with lumbar spondylosis prevalence estimated at 40% to 85% [96]. Intervertebral disc degeneration (IDD) is a multifactorial process characterized by altered biomechanics, extracellular matrix imbalance, increased proinflammatory cytokines, and increased apoptosis and senescence in nucleus pulposus cells [96]. Mechanical progression and disc space narrowing lead to adjacent level pedicle approximation and narrowing of the intervertebral foraminal canal [96]. Laxity of ligaments and vertebral column translates into altered loading mechanics and pressure relationships on vertebone and joint surfaces, influencing osteophyte formation and facet joint hypertrophy [96]. Altered biomechanics from IDD lead to further degenerative changes and osteophyte formation, potentially causing lumbar central and foraminal stenosis [96]. The observed epidemiology of lumbar spinal degeneration is consistent with an ordered progression beginning in the anterior structures for the majority of individuals [35]. Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels [36]. In type I sagittal profiles, disc degeneration is accelerated by regional kyphosis, while in type II profiles, excessive mechanical stress is directly loaded at the thoracolumbar apex [70]. Wedge-shaped vertebrae is an independent risk factor for upper lumbar disc herniation [202]. Abnormal mechanical stress may contribute to intervertebral disc degeneration in old thoracolumbar fractures with kyphosis [140]. Both damage and strain rate have a significant effect on the mechanical behavior of lumbar intervertebral disc fracture under high loading rates [159]. Spinal musculature plays an important role in spinal sagittal imbalance in patients with lumbar disc herniation [188].

Inflammatory and Chemical Pathophysiology

Chemical factors play a role in radiculopathy caused by lumbar disc herniation [120]. TNF-α, interleukin-1β (IL-1β), and interleukin-6 (IL-6) are found in facet joint tissues in degenerative lumbar disorders [120]. IL-6 from the synovium and cartilage of facet joints is elevated mainly in lumbar spinal canal stenosis and related degenerative conditions [120]. IL-1β is present in higher concentrations with lumbar spinal stenosis and degenerative changes compared with lumbar herniated disks [120]. Higher expression of IL-1β is associated with leg pain and declining quality of life in lumbar degenerative patients [120]. IL-1β stimulates the production of matrix metalloproteinases (MMPs) through activation signaling pathways [120]. IL-1β and MMPs are markedly increased in degenerative facets, leading to further proteoglycan degeneration and destruction of cartilage and joint [120]. Phospholipase A₂ mediates mechanical hyperalgesia [120]. Nitric oxide inhibits mechanical hyperalgesia and produces thermal hyperalgesia [120]. MMP-2 (gelatinase A) and MMP-9 (gelatinase) degrade gelatin and other matrix molecules and act synergistically with MMP-1 [120]. MMP-1 (collagenase-1) degrades collagen [120]. MMP-3 (stromelysin-1), along with MMP-1 and MMP-2, may play a role in the spontaneous regression of the herniated disk [120]. IL-1, TNF-α, and prostaglandin E₂ promote matrix degradation and enhance production of MMPs [120]. Calcitonin gene-related peptide (CGRP), glutamate, and substance P modulate dorsal root ganglion responses [120]. IL-6 induces synthesis of tissue inhibitor of metalloproteinase-1 (TIMP-1) [120]. TIMP-1 inhibits MMPs [120]. The TGF-β superfamily blocks synthesis of MMPs [120]. Insulin-like growth factor I (IGF-I) and platelet-derived growth factor (PDGF) have an antiapoptotic effect [120]. Adiponectin has the potential to be a catabolic mediator of osteoarthritis by increasing several MMPs and inducible nitric oxide synthase (iNOS) [120]. Adiponectin was identified in the process of facet joint osteoarthritis with greater expression compared with IL-1β and TNF-α [120].

Lumbar disc herniation most commonly results from tears in the posterolateral annulus fibrosus, causing pain via mechanical compression of nerve roots or chemical irritation through an active inflammatory cascade [201]. Acute tissue injury through excessive repetitive loading, single overload, or chronic degeneration results in annular tears that allow extrusion of the nucleus pulposus [201]. Injured or degenerated annulus fibrosus can be classified into radial tears, circumferential tears along lamellar boundaries, and rim lesions along the boundary between the annulus fibrosus and cartilaginous endplates [201]. Reherniation can occur if the annulus injury is not repaired [201]. TNF-α and phosphorylation of ERK in the dorsal root ganglion and spinal cord are involved in mechanisms of sciatica [25]. Diffusion tensor imaging (DTI) is a potential tool for functional diagnosis of lumbar nerve damage in patients with lumbar disc herniation [195]. Microstructural changes in compressed nerve roots treated by percutaneous transforaminal endoscopic discectomy can be evaluated using diffusion tensor imaging on MRI [25].

Clinical Presentation and Differential Diagnosis

Intervertebral disc disease and disc herniation are most prominent in otherwise healthy people in the third and fourth decades of life [64]. The usual history of lumbar disc herniation is repetitive lower back and buttock pain relieved by rest, suddenly exacerbated by a flexion episode with the appearance of leg pain [64]. Most radicular pain from nerve root compression caused by a herniated nucleus pulposus is evidenced by leg pain equal to or greater than the degree of back pain [64]. Pain from disc herniation usually varies, increasing with activity, especially sitting and driving [64]. Pain can be decreased by rest, especially in the semi-Fowler position, and exacerbated by straining, sneezing, or coughing [64]. Weakness and paresthesias in disc herniation are usually intermittent, vary with activity, and are localized to the neurologic level of involvement [64]. Numbness and weakness in the involved leg and occasionally pain in the groin or testis can be associated with a high or midline lumbar disc herniation [64]. Cauda equina syndrome symptoms include numbness and weakness in both legs, rectal pain, numbness in the perineum, and paralysis of the sphincters [64]. Acute disc herniation patients often show marked paraspinal spasm sustained during walking or motion [64]. A positive Lasègue sign or straight-leg raising should elicit buttock and leg pain distal to the knee [64]. Contralateral leg pain produced by straight-leg raising is regarded as pathognomonic of a herniated intervertebral disc [64]. Atrophy of the involved limb may be present if leg pain has persisted for any length of time [64].

Unilateral disc herniation at L3-4 usually compresses the L4 root [64]. L4 root compression results in sensory deficit in the posterolateral thigh, anterior knee, and medial leg [119]. L4 root compression results in motor weakness of the quadriceps and hip adductors [119]. L4 root compression results in reflex changes of the patellar tendon and anterior tibial tendon [119]. Unilateral disc herniation at L4-5 results in compression of the L5 root [119]. L5 root compression results in sensory deficit in the anterolateral leg, dorsum of the foot, and great toe [119]. L5 root compression results in motor weakness of the extensor hallucis longus, gluteus medius, and extensor digitorum longus and brevis [119]. L5 root compression usually results in no reflex change, though a diminished posterior tibial reflex is possible but difficult to elicit [119]. S1 root compression results in sensory deficit in the lateral malleolus, lateral foot, heel, and web of fourth and fifth toes [119]. S1 root compression results in motor weakness of the peroneus longus and brevis, gastrocnemius-soleus complex, and gluteus maximus [119]. S1 root compression results in reflex changes of the Achilles tendon [119].

The differential diagnosis of back and leg pain includes diseases intrinsic to the spine and diseases involving adjacent organs causing referred pain [119]. Common diseases that can mimic disc disease include ankylosing spondylitis, multiple myeloma, vascular insufficiency, arthritis of the hip, osteoporosis with stress fractures, extradural tumors, peripheral neuropathy, and herpes zoster [119]. Infrequent causes of sciatica not related to disc herniation include synovial cysts, rupture of the medial head of the gastrocnemius, sacroiliac joint dysfunction, lesions in the sacrum and pelvis, and fracture of the ischial tuberosity [119].

Discogenic back pain is secondary to intervertebral disc degeneration without other pathologic entities such as spinal instability, fractures, dislocations, or neural compression [14]. Examination for discogenic back pain reveals a paucity of physical findings, back pain greater than leg pain, and absence of radiculopathy or tension signs [14]. Radiographs for discogenic back pain are negative for instability but may show disc space narrowing or other stigmata of spondylosis [14]. MRI for discogenic back pain typically reveals decreased signal intensity in the disc space on T2-weighted imaging, with or without annular tear or high-intensity zone [14]. Discography is a controversial preoperative study designed to correlate MRI findings with a clinically significant pain generator [14]. For discography to be considered reliably positive, the procedure must elicit pain after injection similar to that usually described by the patient [14]. Evidence suggests that annular tears created by the needle during discography may accelerate the rate of symptomatic disc degeneration [14].

Classification

Terminology: The term "disc bulges" remains a source of confusion and disagreement among many practitioners [17].

Modified Migrated Lumbar Disc Herniation: A modified classification for migrated lumbar disc herniation demonstrates good reliability, with the experience level of spine surgeons not affecting this reliability [83].

Lumbar Disc Degeneration (8-Grade System): A modified system for lumbar disc degeneration comprises 8 grades, where Grade 1 corresponds to no disc degeneration and Grade 8 corresponds to end-stage degeneration [130].

Pfirrmann: Pfirrmann’s classification grades intervertebral disc degeneration from Grades I to V, with Grades I, II, and III defined as the early stage and Grades IV and V as the advanced stage [160].

Lee: The Lee classification is used to categorize the prolapsed type of lumbar disc herniation based on imaging data of the prolapsed nucleus pulposus [60].

Paraspinal Muscle Fat Infiltration: A 4-grade fat infiltration system for paraspinal muscles is more effective in predicting lumbar disc herniation compared to a 3-grade system [182, 189].

Lewin (Modified): The Lewin classification for lumbar disc degeneration was modified to distinguish between moderate and severe loss of tissue by subdividing Grade 3 into Grade 3A and Grade 3B [85]. In the modified Lewin classification, Grade 3A is characterized by major defects in the nucleus, such as fissures, lobulation, or cavities, and frequently thinning or intense brown color [85]. Grade 3B is characterized by the features of Grade 3A plus gross loss of tissue from both the nucleus and anulus [85].

Other Considerations: A YOLO-based deep learning model can detect lumbar disc herniation at the L4–L5 and L5–S1 levels on sagittal MRI with clinically meaningful performance [87]. T2-weighted MRI texture analysis applied to the L4-L5 and L5-S1 discs achieves an accuracy of 83%, specificity of 83%, sensitivity of 82%, negative predictive value of 94%, precision of 56%, and an area-under-curve of 0.91 for classifying symptomatic versus asymptomatic low back pain cases [157]. A rat model of lumbar disc herniation induced by puncture can construct different types of herniation, including disc degeneration, bulging, central herniation, and lateral herniation [193].

Clinical Presentation

History and Symptoms

Most patients attribute back and leg pain to a traumatic incident, yet close questioning frequently reveals intermittent episodes of back pain persisting for months or years before the onset of severe leg pain [64]. The typical history involves repetitive lower back and buttock pain relieved by rest, which is suddenly exacerbated by a flexion episode accompanied by the appearance of leg pain [64]. Radicular pain from nerve root compression caused by a herniated nucleus pulposus is usually evidenced by leg pain equal to, or often greater than, the degree of back pain [64]. When leg pain is minimal and back pain is predominant, great care is required before diagnosing a symptomatic herniated intervertebral disc [64]. Pain typically decreases with rest, especially in the semi-Fowler position, and is exacerbated by straining, sneezing, or coughing [64]. Skepticism is warranted if the pain pattern is bizarre or uniform in intensity [64]. Weakness and paresthesias are additional symptoms; weakness is usually intermittent, varies with activity, and localizes to the neurologic level of involvement, while paresthesias vary and remain limited to the dermatome of the involved nerve root [64]. Generalized complaints of weakness or paresthesias should prompt questioning of a simple unilateral disc herniation diagnosis [64].

Gluteal pain relates to low lumbar disc hernia, with the L4/5 level being the main responsible level [134]. Diskogenic pain related to degeneration or herniation may worsen in flexion, while sitting, or with prolonged axial loading, and is often described in a diffuse, bandlike distribution [156]. In patients with lumbar disc herniation and associated radiculopathy, a combination of clinical features predicted the presence or absence of histologically confirmed inflammation [127].

Physical Examination

Patients with acute pain usually exhibit marked paraspinal spasm sustained during walking or motion [64]. A scoliosis or list in the lumbar spine may be present, and normal lumbar lordosis is often lost [64]. As the acute episode subsides, spasm diminishes remarkably, and loss of normal lumbar lordosis may be the only telltale sign [64]. Point tenderness may be present over the spinous process at the level of the involved disc, with pain extending laterally in some patients [64]. If nerve root irritation is present, it centers over the length of the sciatic nerve, in the sciatic notch, and more distally in the popliteal space [64]. Stretch of the sciatic nerve at the knee should reproduce buttock, thigh, and leg pain distal to the knee [64].

A Lasègue sign is usually positive on the involved side, and a positive straight-leg raising should elicit buttock and leg pain distal to the knee [64]. Contralateral leg pain produced by straight-leg raising is regarded as pathognomonic of a herniated intervertebral disc [64]. The absence of a positive Lasègue sign should make one skeptical of the diagnosis, although older individuals may not have a positive sign and tend toward more claudicatory symptoms [64]. Inappropriate findings and inconsistencies in the examination usually indicate a nonorganic origin [64]. If leg pain has persisted for any length of time, atrophy of the involved limb may be present, shown by asymmetric girth of the thigh or calf [64].

Unilateral disc herniation at L3-4 usually compresses the L4 root as it crosses the disc before exiting at the L4-5 intervertebral foramen below the L4 pedicle [64]. Pain from L3-4 herniation may localize around the medial side of the leg, with numbness over the anteromedial aspect of the leg and weakness of the anterior tibial muscle [64]. The ipsilateral hip and knee may be flexed and externally rotated to relieve root tension [139]. Pain with straight leg raise testing results from increased nerve root tension and a lack of normal excursion of the root at the herniation site [139]. A positive crossed straight leg raise test has higher specificity than a positive ipsilateral test, but sensitivity varies [139]. The presence of sciatica is the most sensitive and specific finding for lumbar disc herniation [139].

The accuracy of individual clinical index tests used to predict imaging findings of nerve root impingement in patients with chronic lumbar radiculopathy is low when applied in specialised care, but clinicians' overall evaluation improves diagnostic accuracy slightly [37]. For detecting lumbar disk herniation, the straight leg raise is more sensitive but less specific than the contralateral straight leg raise in patients with single leg radicular pain [156].

Neurologic Deficits by Level

Unilateral disc herniation at L3-4 usually compresses the L4 root, with pain localized around the medial side of the leg and numbness over the anteromedial aspect of the leg [64]. Weakness from L3-4 herniation may involve the anterior tibial muscle, evidenced by inability to perform specific movements [64]. The autonomous zone for the L5 nerve is the dorsal first web of the foot and the dorsum of the third toe [64]. Weakness from L5 involvement may involve the extensor hallucis longus, gluteus medius, or extensor digitorum longus and brevis [64]. Reflex change usually is not found with L5 involvement, though a diminished posterior tibial reflex is possible but difficult to elicit [64].

L4: Motor function involves knee extension; sensory distribution includes the lateral thigh, anterior knee, and medial leg; the reflex is patellar [156]. L5: Motor function involves ankle/toe dorsiflexion and hip abduction; sensory distribution includes the lateral leg and dorsum of the foot; there is no specific reflex [156]. S1: Motor function involves ankle plantar flexion and foot eversion; sensory distribution includes the posterior leg and lateral foot; the reflex is Achilles [156].

Diagnostic Considerations

Symptoms of pressure on the entire cauda equina, including numbness and weakness in both legs, rectal pain, numbness in the perineum, and paralysis of the sphincters, can occur if a fragment is large or the herniation is high [64]. Cauda equina syndrome should be the primary consideration in patients who complain of sudden loss of bowel or bladder control [64].

The clinical presentation of recurrent disc herniation may be identical to that of primary herniation but usually has a larger component of axial pain [20]. Making the diagnosis of recurrent disc herniation is significantly more difficult than that of primary disc herniation [20]. Radiographic findings alone are never an indication for surgery, and correlation of imaging with symptoms seems to be the best guarantee of improvement after surgery [30]. Many patients with pain have absent neurologic findings other than sensory changes and have normal imaging studies or studies that do not support the clinical complaints and findings [23]. The history, physical examination, and imaging studies must all confirm the same pathologic process as the source of symptoms if surgical intervention is to be reproducibly successful [27]. Preoperative imaging studies cannot predict the clinical outcome of percutaneous lumbar discectomy [45].

Malignant tumours involving the sciatic nerve are easily misdiagnosed as lumbar disc herniation due to similar clinical manifestations and low incidence [111]. Parasite infestation should be considered even in cases with obvious MRI of lumbar intervertebral disc herniation [75]. Atypical femoral fracture may mimic lumbar radiculopathy [76].

Investigations

MRI: Magnetic resonance imaging is the standard for advanced spinal imaging, superior to CT in most circumstances for identifying infections, tumors, and degenerative changes within the discs [104]. It directly images neural structures and the intervertebral disc more effectively than CT [104]. MRI allows visualization of the nerve root within the foramen, a region difficult to assess with postmyelography CT because contrast agent does not fully extend through the foramen [104]. Prevalence of MRI evidence for lumbar disc degeneration is 35% in patients aged 20 to 39 years and 100% in patients older than 50 years [104]. Findings must be carefully correlated with the clinical impression to avoid poor outcomes [104]. The most effective approach is to pose a specific question derived from history and physical examination, focusing on neural compression, instability, or deformity [104].

MRI-Specific Findings: A positive T2-weighted image showing a high-intensity zone (HIZ) indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain [163]. Clinical predictors for resorption of lumbar disc herniation include herniation size, type, composition, rim enhancement on MRI, and involvement of the posterior longitudinal ligament [79]. Patients with Modic changes have a higher incidence risk of recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy [31]. Patients who are diabetic, smokers, or have contained disk herniation on MRI should be counseled for a higher risk of recurrence after biportal endoscopic diskectomy [209]. The type and extent of cervical disc herniation measured on MRI prior to surgery correlated neither to the severity of symptoms at presentation nor to clinical outcomes at two years postoperatively [71]. The classification term 'disc bulges' is a source of confusion and disagreement among many practitioners, although other commonly supported nomenclatures have strong interobserver reliability [17]. Parasite infestation should be considered even in cases with obvious MRI findings of lumbar intervertebral disc herniation [75].

CT: CT is the diagnostic imaging modality of choice for injuries involving the thoracic, lumbar, or sacral regions of the spine [110]. Postmyelography CT improves the value of myelography in evaluating spinal stenosis and in specific settings where MRI is inconclusive [112].

Myelography: Myelography is indicated when MRI cannot be obtained, when there is suspicion of an intraspinal lesion, in patients with spinal instrumentation causing artifact, or when diagnosis is questionable due to conflicting clinical findings [112]. It is valuable in evaluating previously operated spines and in patients with marked bony degenerative change that may be underestimated on MRI [112].

Physical Examination: The accuracy of individual clinical index tests used to predict imaging findings of nerve root impingement in patients with chronic lumbar radiculopathy is low when applied in specialised care [37]. Clinicians' overall evaluation improves diagnostic accuracy slightly for chronic lumbar radiculopathy compared to individual index tests [37]. Prior knowledge of lumbar MRI results may introduce bias into the pinprick sensory testing component of the physical examination for lumbar radiculopathy [204]. In patients with discogenic back pain, examination typically reveals a paucity of physical findings, back pain greater than leg pain, and an absence of radiculopathy or tension signs [14]. Lumbar range of motion is mildly limited, especially in flexion, and straight-leg raising typically causes back and buttock pain but no pain distal to the knee [19]. Examination reveals no weakness or reflex changes if intervertebral disc degeneration (IDD) is the only diagnosis [19]. If three or more Waddell signs are present during examination, an alternative diagnosis to IDD is more likely [19].

Diagnostic Procedures: Discography is a controversial preoperative study designed to correlate MRI findings with a clinically significant pain generator [14]. For discography to be considered reliably positive, the procedure must elicit pain after injection similar to that usually described by the patient (concordant pain) [14]. The procedure should involve at least one minimally painful, nonconcordant level and be performed at multiple levels to include all abnormal levels and one or more normal levels as identified on MRI [14]. Evidence suggests that annular tears created by the needle during discography may accelerate the rate of symptomatic disc degeneration [14]. Consequently, discography is falling out of favor due to this potential for accelerating symptomatic disc degeneration [14]. MRI with intravascular contrast material has been helpful in identifying recurrent herniations, though it is difficult to distinguish a peridural scar from a small recurrent herniation [20]. Some authors have recommended provocative discography to evaluate adjacent levels, but it has not been found to be reliable in the context of low-grade isthmic spondylolisthesis evaluation [57].

Other Considerations: Ascending lumbar venography was as accurate as myelography (86%) in localizing herniation of a lumbar disc in surgically proved cases [48]. Ultrasound imaging can be considered a useful tool to detect changes in the sciatic nerve due to disc herniation [197]. An ultrasound-guided disc pain induction test may help diagnose disc degeneration and identify culprit lesions, even when multiple discs exhibit findings of degeneration [68].

Treatment

Non-Operative

The natural history of degenerative disc disease involves recurrent pain episodes followed by periods of significant or complete relief [27]. More than half of patients seeking treatment for low back pain recover within 1 week, and 90% recover within 1 to 3 months [14]. Conservative management for discogenic back pain includes NSAIDs, physical therapy, and conditioning [14]. Patient education regarding the self-limiting nature of discogenic back pain is essential [14]. The literature supports an active care approach that minimizes centrally acting medications [27].

Steroid injections provide short-term improvement in lumbar radiculopathy symptoms but do not affect long-term outcomes [135, 23]. A prospective randomized controlled trial demonstrated that transforaminal steroid injection resulted in a greater than 50% pain reduction at 1 month in 54% of patients, significantly outperforming normal saline or local anesthetic injections [135]. Repeat steroid injections are less likely to provide significant relief [135]. Evidence suggests that local anesthetics with or without steroids are equally effective as steroids alone for epidural injections in treating disc herniation and radiculitis [66]. Therapeutic injections help manage pain and may decrease the need for oral analgesics in severe acute disc injury pain [66]. Platelet-rich plasma epidural injection is recommended for treating single-level lumbar herniated nucleus pulposus due to its efficacy and safety [123].

A combination of non-surgical spinal decompression therapy with routine physical therapy is more effective than physical therapy alone in improving pain, lumbar range of motion, back muscle endurance, functional disability, and physical role domain of quality of life after 4 weeks [181]. The effect of serotonin receptor blockers was higher in patients with uncontained disc herniation than in those with contained disc herniation [32]. Clinical predictors for resorption include herniation size, type, composition, rim enhancement on MRI, and involvement of the posterior longitudinal ligament [79].

Operative

Indications: Radiographic findings alone are never an indication for surgery [30]. The primary indication for surgery in spinal stenosis is increasing pain resistant to conservative measures [30]. A patient’s inability to tolerate the restricted lifestyle necessitated by the disease and the failure of a good conservative treatment regimen should be the primary determining factors for surgery [30]. If surgery is necessary for nonprogressive neurologic deficits, it usually can be delayed 6 to 12 weeks to allow adequate opportunity for improvement [27]. Patients with cervical myelopathy or progressive neurologic deficits are best treated surgically [23]. Delaying surgical treatment for a trial of nonoperative treatment has not been shown to affect outcome [30]. One study reported less favorable results in patients who had symptoms for more than 33 months [30]. At 2 years, microdiscectomy was superior to nonoperative care for chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation [81]. Microdiscectomy is more cost-effective than a 6-month nonsurgical care regimen for chronic radiculopathy [175]. Continued nonsurgical treatment strategies were not cost effective after 6 weeks of nonsurgical treatment in patients with imaging confirmed spine pathology [135]. Evidence is lacking concerning the optimal treatment of lumbar disc induced sciatica [62].

Surgical Approach / Technique: Multiple systematic reviews have failed to demonstrate a consistent benefit of any one surgical technique (open diskectomy, microdiskectomy, tubular microdiskectomy, percutaneous or endoscopic diskectomy) over any other [135]. Biportal endoscopic discectomy is as effective as microscopic discectomy in treating single-level lumbar disc herniation but has distinct advantages in terms of postoperative wound complications [5]. Unilateral biportal endoscopic discectomy yielded similar clinical outcomes to percutaneous endoscopic lumbar discectomy, including pain control and patient satisfaction [144]. The clinical effect of the unilateral biportal endoscopy technique in treating upper lumbar disc herniation was reliable [149].

Percutaneous endoscopic transforaminal discectomy is safe and effective in the long term and is applicable to the treatment of recurrent lumbar disc herniation [12]. Percutaneous endoscopic lumbar discectomy is a safe and efficacious technique to relieve symptoms of herniated discs, with improvement in back pain and leg symptoms translating to improvement in quality of life [121]. Excellent clinical and minimally invasive outcomes can be obtained in the surgical treatment of lumbar disc herniation via the interlaminar approach assisted by full endoscopic technique [40]. Percutaneous endoscopic interlaminar discectomy and percutaneous endoscopic transforaminal discectomy have similar clinical efficacy in treating L5–S1 disc herniation [109]. Percutaneous endoscopic interlaminar discectomy has reliable efficacy and safety for treating highly downward-migrated disc herniation, and its long-term efficacy is comparable to posterior lumbar interbody fusion [114]. Percutaneous transforaminal endoscopic discectomy has comparable efficacy in treating upper lumbar disc herniation as it does in treating lower lumbar disc herniation [117]. Percutaneous transforaminal endoscopic surgery is an effective and safe method to treat calcified lumbar disc herniation [133]. Transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation is a safe and effective procedure [146]. Transforaminal endoscopic lumbar discectomy was effective and safe in the treatment of disc herniation with leg pain and numbness [150]. A targeted and quantificational foraminoplasty device is efficient and safe for percutaneous transforaminal endoscopic discectomy in treating lumbar disc herniation at the L5–S1 level [129].

Implant Selection: Total disc arthroplasty is a surgical option for patients with degenerative disc disease at a single level (L4–L5 or L5–S1) in the lumbar spine with the absence of spondylolisthesis and no relief from 6 months of nonoperative therapy [14]. Outcomes in lumbar total disc replacement patients with herniated nucleus pulposus and radiculopathy were similar to outcomes in patients with the classic indication, suggesting these diagnoses may not have to be considered absolute or relative contraindications [72]. In direct comparison with anterior interbody fusion, total disc arthroplasty showed equivalent clinical results and no catastrophic failures at 2-year follow-up [14]. Significant concerns regarding total disc arthroplasty include long-term results, design issues, cost, and the safety of revision procedures [14]. Intradiscal electrotherapy may be effective in early conditions with less than 50% loss of disc height but not in more advanced disease [14]. Long-term follow-up suggests that symptomatic improvement from intradiscal electrotherapy often lasts less than 1 year, and this procedure has been largely abandoned [14]. Currently no good surgical option is available that reliably reduces symptoms of discogenic back pain [14]. Surgery should be avoided whenever possible for discogenic back pain, and conservative measures should be exhausted before any consideration is given to surgical intervention [14].

Other Considerations: In the Maine Lumbar Spine Study, pain in the lower extremity at one year had decreased in 81 percent of 209 patients who had had a disc excision compared with 56 percent of 165 patients who had been managed nonoperatively for lumbar disc herniation [73]. In the Maine Lumbar Spine Study, the predominant symptom was much better or gone in 71 percent of the 209 patients who had had a disc excision compared with 43 percent of the 167 nonoperatively managed patients [73]. Better operative outcomes were associated with lower population-based rates of operative treatment [73].

Prognostic factors for better results include a disc herniation, stenosis at a single level, weakness of less than 6 weeks’ duration, monoradiculopathy, and age younger than 65 years [30]. Depression, psychiatric disease, cardiovascular disease, higher body mass index, scoliosis, and disorders affecting ambulation have been associated with a poorer prognosis [30]. Patients whose predominant complaint was leg pain improved significantly more with operative treatment than those whose predominant complaint was low back pain [30]. Reoperation rates vary from 6% to 23% [30]. Obese patients who underwent biportal endoscopic lumbar discectomy for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients [46].

Most lumbar spine pathologies in recreational athletes can be managed nonsurgically with excellent outcomes, while surgical treatment is a viable option with good outcomes for those who fail nonsurgical treatment or have neurological risk [44]. In a 2011 analysis of 342 professional athletes with lumbar disk herniations, the overall return to play was 82% and the return to play was 81% in those who underwent surgical decompression [135]. In a 2010 analysis of 137 NFL players with lumbar disk herniations, greater career longevity was demonstrated in those who underwent surgery (36 games played) compared with those treated nonsurgically (20 games played) [135]. In a retrospective review of the National Football League’s surveillance database, players with thoracic disk herniations missed significantly more practices and games on average (72 and 17, respectively) than those with lumbar disk herniations (39 and 11, respectively) [131].

The Spine Patients Outcomes Research Trial demonstrated that surgery showed improvements in all primary outcome measures at 2, 4, and 8 years for lumbar disk herniation [135]. In the Spine Patients Outcomes Research Trial, patients with symptoms greater than six months, sequestered fragments, increased back pain, and who were not working had relatively increased benefits from surgery [135]. In the Spine Patients Outcomes Research Trial, preoperative epidural steroid injection did not influence surgical outcome [135]. In the Spine Patients Outcomes Research Trial, obesity is associated with less clinical benefit from surgical or nonsurgical treatment [135]. In the Spine Patients Outcomes Research Trial, more proximal disk herniations are associated with greater degree of postoperative improvement [135]. A discectomy does not always provide the final solution to lumbar disc disease in children, but careful selection of patients and follow-up can produce satisfactory long-term results in most [8].

Revision: Recurrent lumbar disk herniation is the most common complication following primary open diskectomy, defined as recurrent back and/or leg pain after a definite pain-free period of at least 6 months [15]. Most recurrences happen in the relatively early postoperative period, primarily the first 6 months after surgery [20]. No operative technique has been shown to reduce the incidence of recurrent disc herniations, which is reported in 3% to 7% of patients [20]. More aggressive disc removal does not reduce the incidence of recurrent disc herniation and does not reduce the motion segment [20]. MRI with intravascular contrast material has been helpful in identifying recurrent herniations, but it is difficult to distinguish a peridural scar from a small recurrent herniation [20]. The principles of identifying and protecting the nerve root and then removing the herniation for recurrent herniation are the same as for a primary discectomy [20]. The area of exposure for recurrent herniation surgery generally should be larger, although usually the procedure still can be done on an outpatient basis [20]. Treatment of recurrent disc herniation is one of the advantages of the transforaminal endoscopic approach, which can be used for recurrence after a traditional microdiscectomy [20]. If both the primary and recurrence approaches are transforaminal, the total level of invasiveness typically is still less than a primary microscopic approach, since there is no violation of the facet joint [20]. Repeat surgery for a recurrent lumbar disc herniation was performed with good probability for improvement, although not as good as for primary lumbar disc herniation surgery, and patients undergoing repeated surgery were less satisfied [78]. Spinal fusion is not done for recurrent herniation unless an unstable spine is created by the dissection or was identified preoperatively as a correctable and symptomatic problem [20].

Postoperative Care and Rehabilitation: This document describes the protocol for a randomised controlled trial to assess the impact of activity restrictions on clinical outcomes following lumbar discectomy, aiming to provide an evidence base for postoperative care [9]. The results of the REALISE trial may lead to a more consistent postoperative strategy for patients who will undergo lumbar disc surgery [42]. The FASTER trial involves recruiting patients with symptoms, signs, and radiological findings of either lateral nerve root compression or disc prolapse scheduled for surgery who will be randomised to receive a six-week programme of postoperative rehabilitation or the relevant surgeon's usual postoperative care [165].

Complications

Recurrent Disc Herniation

The incidence of recurrent disc herniation is reported in 3% to 7% of patients [20]. No operative technique has been shown to reduce the incidence of recurrent disc herniations [20], and more aggressive disc removal does not reduce the incidence of recurrent disc herniations [20]. Seven percent of lumbar disc patients had a residive lumbar disc operation within five years of their first operation [34]. The 1-year postoperative recurrence rate for day surgery using percutaneous endoscopic lumbar discectomy was relatively high [69]. Patients who have recurrent lumbar disc herniation report more back pain if the herniation recurs compared to those undergoing the primary procedure [13]. Repeat microscopic discectomy and instrumented fusion for recurrent lumbar disc herniation yielded similar clinical outcomes but with dramatically higher reoperation rates over 5 years in the repeat microscopic discectomy group [47].

Surgical Complications

Complications of lumbar disc surgery range from none to more than 10% [80]. The reoperation rate for lumbar disc surgery ranges from 4% to more than 20% [80]. Specific complication incidences include cauda equina syndrome at 0.2% [80], thrombophlebitis at 1% [80], pulmonary embolism at 0.4% [80], wound infection at 2.2% [80], pyogenic spondylitis at 0.07% [80], postoperative discitis at 2% [80], dural tears at 1.6% [80], and nerve root injury at 0.5% [80]. Laceration of abdominal vessels is a rare complication of lumbar disc surgery [80], and injury to abdominal viscera is a rare complication of lumbar disc surgery [80]. Complications of lumbar disc herniation surgery include vascular injury, nerve root injury, infection, discitis, cauda equine syndrome, and dural tears [154]. The incidence of infection in lumbar disc herniation surgery is 1% but is increased in diabetics [154]. Biportal endoscopic discectomy has distinct advantages in terms of postoperative wound complications compared to microscopic discectomy [5]. The effect of dural tear on in-hospital morbidity, mortality, and healthcare burdens was more significant in lumbar spinal decompression than in lumbar discectomy [170]. Old age, severe grade of surgical-level disc degeneration, and more disc degeneration levels significantly increased the incidence of complications in percutaneous endoscopic transforaminal discectomy [86]. In the short term, patients with >50% inferior articular process defects after percutaneous endoscopic interlaminar lumbar discectomy show no difference in lumbar stability or clinical outcomes compared to those with ≤50% defects [84]. Complete inferior articular process loss after percutaneous endoscopic interlaminar lumbar discectomy remains a concern for long-term instability [84].

Failed Spine Surgery and Revision

Complications of repeat spine surgery have been reported to be three to five times higher than for primary surgeries [179]. Satisfactory results from reoperation for failed spine surgery have been reported to be 31% to 80% [179]. As the frequency of repeat back surgeries increases, the chance of a satisfactory result decreases precipitously [179]. Adverse factors for repeat spine surgery include scarring, previous infection, repair of pseudarthrosis, and adverse psychologic factors [179]. The best results from repeat surgery for disc problems occur in patients who have experienced 6 months or more of complete pain relief after the first procedure [179]. The best results from repeat surgery for disc problems occur when leg pain exceeds back pain [179]. The best results from repeat surgery for disc problems occur when a definite recurrent disc can be identified [179]. Pseudarthrosis, instability, and recurrent herniations are the diagnoses most likely to respond to further operative intervention after failed spine surgery [179].

Adjacent Segment and Degenerative Changes

A rare occurrence of massive thoracic disc herniation with severe neurological problems due to adjacent instability ascending from a previous lumbar spine fusion has been documented [41]. The presence and progression of lumbar spinal endplate lesions are mainly attributed to lumbar disc herniation and higher hip circumference in men [11]. Signs of early disc degeneration related to tumor treatment can be seen in the intervertebral discs of radiotherapy-treated childhood brain tumor survivors [24].

Diagnostic and Interventional Complications

Dural puncture has been estimated to occur in 0.5% to 5% of patients having cervical or lumbar epidural steroid injections [158]. Epidural abscess, epidural hematoma, durocutaneous fistula, and Cushing syndrome have been reported as individual case reports following epidural corticosteroid injections [158]. The most adverse event imputed during an epidural injection is a vasovagal reaction [158]. Minor complaints caused by corticosteroid injected into the epidural space include nonpositional headaches, facial flushing, insomnia, low-grade fever, and transient increased back or lower extremity pain [158]. Several large series involving nearly 5000 patients with over 8000 transforaminal lumbar epidural injections reported no major adverse events [158]. The incidence of postinjection headache in large series of transforaminal lumbar epidural injections was less than 1% [158]. Increased leg or back pain following transforaminal lumbar epidural injections occurred in less than 1% of patients in large series [158]. A retrospective analysis of vertebral body fractures following epidural steroid injections is cited in the literature [1].

Recovery

Light activity (weeks): If surgery is necessary for lumbar disc herniation, it usually can be delayed 6 to 12 weeks to allow adequate opportunity for improvement [27]. During this period, the literature supports an active care approach that minimizes centrally acting medications for lumbar disc disease [27]. The judicious use of epidural steroids is supported for short-term relief, but long-term results and repeated use are questionable [27].

Full activity (months): No specific month range for full activity return is provided in the evidence.

Complete recovery / outcome plateau (months): The primary benefit of surgery for lumbar disc herniation has been noted to occur early on in the first year after surgery, but with time the statistical significance of the improvement appears to be lost [27].

Rehabilitation protocol: No specific rehabilitation protocol details, such as PT phasing or immobilisation duration, are provided in the evidence.

Functional milestones: No validated PROM trajectories or specific outcome-measure benchmarks are provided in the evidence.

Other Considerations: Lumbar discal hernia removal techniques have evolved in instrumentation over the last 30 years without any spectacular improvement in clinical results [3]. Patients who have recurrent lumbar disc herniation are no worse off pre- or post-operatively than those undergoing the primary procedure, but do report more back pain if the herniation recurs [13]. A propensity-matched analysis of 450 patients demonstrated that repeat microscopic discectomy and instrumented fusion for recurrent lumbar disc herniation yielded similar clinical outcomes but with dramatically higher reoperation rates over 5 years in the repeat microscopic discectomy group [47]. Transforaminal endoscopic discectomy is safe and effective in the long term and is applicable to the treatment of recurrent lumbar disc herniation [12]. Percutaneous endoscopic lumbar discectomy can be considered as an alternative technique to treat multiple episodes of lumbar disc herniation by preserving normal anatomic structures [88]. DIAM implantation significantly decreased reoperation rate for lumbar disc herniation in a 15-year survivorship analysis [77]. A dose-response relationship exists between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine [213]. The risk of any additional lumbar spine surgery and additional lumbar disc herniation surgery was similar in adolescents and young adults compared to other groups [7]. In the short term, patients with greater than 50% inferior articular process defects after percutaneous endoscopic interlaminar lumbar discectomy show no difference in lumbar stability or clinical outcomes compared to those with 50% or less defects, though complete inferior articular process loss remains a concern for long-term instability [84]. Intradiscal platelet-rich plasma injection can significantly alleviate long-term pain and dysfunction in lumbar disc herniation patients, with efficacy greater than that of the control treatment [190].

Key Evidence

• [L1] The overall incidence of regression is 63% among non-surgically treated symptomatic lumbar disc herniation patients. [2] (10.1186/s12891-020-03548-z)
• [Paper] Lumbar discal hernia removal techniques have greatly evolved in terms of instrumentation over the last 30 years, but without any spectacular improvement in clinical results. [3] (10.1016/j.otsr.2012.11.005)
• [L3] On average, most lumbar disc herniations do not change over a four- to eight-year period. [4] (10.1186/s12891-016-0865-6)
• [L1] BED is as effective as MD in treating single-level lumbar disc herniation but has distinct advantages in terms of postoperative wound complications. [5] (10.1302/0301-620x.107b5.bjj-2024-1560.r1)
• [L5] Lumbar disk herniation has a good prognosis with 82% of professional athletes returning to play after recovery. [6] (10.5435/jaaos-d-16-00135)
• [L3] The risk of any additional lumbar spine surgery and additional lumbar disc herniation surgery was similar in adolescents and young adults. [7] (10.1302/0301-620x.101b12.bjj-2019-0621.r1)
• [L4] A discectomy does not always provide the final solution to lumbar disc disease in children, but careful selection of patients and follow-up can produce satisfactory long-term results in most. [8] (10.2106/00004623-199805000-00009)
• [L2] This document describes the protocol for a randomised controlled trial to assess the impact of activity restrictions on clinical outcomes following lumbar discectomy, aiming to provide an evidence base for postoperative care. [9] (10.1186/s12891-017-1681-3)
• [L3] The presence and progression of these lesions are mainly attributed to lumbar disc herniation and higher hip circumference in men. [11] (10.1186/s12891-023-06379-w)
• [L4] The TED is safe and effective in the long term and is applicable to the treatment of recurrent lumbar disc herniation. [12] (10.1186/s12891-023-06148-9)
• [L3] Patients who have recurrent lumbar disc herniation are no worse off pre- or post-operatively than those undergoing the primary procedure, but do report more back pain if the herniation recurs. [13] (10.1302/0301-620x.95b1.30413)
• [L5] Recurrent lumbar disk herniation is the most common complication following primary open diskectomy, defined as recurrent back and/or leg pain after a definite pain-free period of at least 6 months. [15] (10.5435/00124635-201006000-00005)
• [L1] Although it appears that the most commonly supported nomenclatures have strong interobserver reliability, the classification term 'disc bulges' is a source of confusion and disagreement among many practitioners. [17] (10.1007/s11999-014-3674-y)
• [L5] [18] (10.1097/01.blo.0000198724.54891.3a)
• [L3] Signs of early disc degeneration related to tumor treatment can be seen in the intervertebral discs of survivors. [24] (10.1186/s12891-023-06509-4)
• [L3] While patients with larger disc herniations might have a greater likelihood of superior clinical outcomes, the previously suggested '6 mm rule' was not supported. [26] (10.1007/s00402-017-2699-6)
• [L3] Patients with Modic changes had a higher incidence risk of recurrent lumbar disc herniation. [31] (10.1186/s13018-020-01695-6)
• [L4] The effect was higher in patients with uncontained disc herniation than in those with contained disc herniation. [32] (10.1097/01.blo.0000065840.77325.8f)
• [L5] The review provides evidence questioning the benefits of traditional surgery for patients with lumbar disc herniation, highlighting issues such as favorable natural history, insufficient evidence for fusion, metallosis, and implant removal. [33] (10.3389/fsurg.2022.814531)
• [L3] Seven percent of the lumbar disc patients had a residive lumbar disc operation within five years of their first operation. [34] (10.1186/1471-2474-8-2)
• [L3] The observed epidemiology of lumbar spinal degeneration in the community-based population is consistent with an ordered progression beginning in the anterior structures, for the majority of individuals. [35] (10.1186/1471-2474-12-202)
• [L4] Modic changes, particularly Type 2, are common radiological findings in lumbar spine imaging, most frequently occurring at L4/L5 and L5/S1 levels. [36] (10.1186/s12891-025-09182-x)
• [L2] The accuracy of individual clinical index tests used to predict imaging findings of nerve root impingement in patients with chronic lumbar radiculopathy is low when applied in specialised care, but clinicians' overall evaluation improves diagnostic accuracy slightly. [37] (10.1186/1471-2474-14-206)
• [L4] Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial. [38] (10.1016/j.spinee.2010.02.005)
• [L4] Excellent clinical and minimally invasive outcomes can be obtained in the surgical treatment of lumbar disc herniation via the interlaminar approach assisted by FE technique. [40] (10.1016/j.spinee.2010.12.006)
• [L5] The case documents a rare occurrence of massive thoracic disc herniation with severe neurological problems due to adjacent instability ascending from a previous lumbar spine fusion. [41] (10.1007/s00402-005-0012-6)
• [L1] The results of this trial may lead to a more consistent postoperative strategy for patients who will undergo lumbar disc surgery. [42] (10.1186/1471-2474-14-124)
• [L5] Most lumbar spine pathologies in recreational athletes can be managed nonsurgically with excellent outcomes, while surgical treatment is a viable option with good outcomes for those who fail nonsurgical treatment or have neurological risk. [44] (10.5435/jaaos-d-24-00979)
• [L3] Preoperative imaging studies cannot predict the clinical outcome of percutaneous lumbar discectomy. [45] (10.2106/00004623-199504000-00011)
• [L3] Obese patients who underwent BELD for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients. [46] (10.1186/s12891-022-06082-2)
• [L3] This propensity-matched analysis of 450 patients demonstrated that repeat MD and IF for recurrent lumbar disc herniation yielded similar clinical outcomes but with dramatically higher reoperation rates over 5 years in the repeat MD group. [47] (10.2106/jbjs.25.01113)
• [L3] Ascending lumbar venography was as accurate as myelography (86 per cent) in localizing herniation of a lumbar disc in surgically proved cases. [48] (10.2106/00004623-197759020-00003)
• [L3] [60] (10.1186/s13018-026-06902-4)
• [L2] Evidence is lacking concerning the optimal treatment of lumbar disc induced sciatica. [62] (10.1186/1471-2474-6-8)
• [L1] Nevertheless, it remains a safe and effective surgical intervention for treating herniated lumbar discs in the context of obesity. [63] (10.1186/s12891-024-07455-5)
• [L4] Age is not a contraindication for decompressive lumbar spine surgery. [65] (10.1186/s13018-020-01968-0)
• [L4] The ultrasound-guided disc pain induction test may help diagnose disc degeneration and identify culprit lesions, even when multiple discs exhibit findings of degeneration. [68] (10.1186/s13018-023-04327-x)
• [L3] Although the 1-year postoperative recurrence rate was relatively high, day surgery for lumbar disc herniation undergoing PELD had advantages in terms of less blood loss intraoperatively, short hospital stay, efficacy for back pain, and efficiency to maintain lumbar physiological curvature. [69] (10.1186/s12891-021-04038-6)
• [L4] In type I, disc degeneration was accelerated by regional kyphosis, while in type II, excessive mechanical stress was directly loaded at the thoracolumbar apex. [70] (10.1186/s12891-021-04033-x)
• [L2] In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. [71] (10.1302/0301-620x.104b11.bjj-2022-0657.r2)
• [L3] Outcomes in lumbar TDR patients with HNP and radiculopathy were similar to outcomes in patients with the classic indication, suggesting these diagnoses may not have to be considered absolute or relative contraindications. [72] (10.1186/1471-2474-12-275)
• [L3] [73] (10.2106/00004623-199906000-00002)
• [Case_report] Parasite infestation should be considered even in cases with obvious MRI of lumbar intervertebral disc herniation. [75] (10.1186/s12891-020-03870-6)
• [Case_report] AFF may mimic lumbar radiculopathy. [76] (10.1186/s12891-022-05990-7)
• [L3] DIAM implantation significantly decreased reoperation rate for lumbar disc herniation in the 15-year survivorship analysis. [77] (10.1186/s12891-021-04929-8)
• [L2] Repeat surgery for a recurrent lumbar disc herniation was performed with good probability for improvement, although not as good as for primary lumbar disc herniation surgery, and patients undergoing repeated surgery were less satisfied. [78] (10.1007/s11999-014-3596-8)
• [L4] Clinical predictors for resorption include herniation size, type, composition, rim enhancement on MRI, and involvement of the posterior longitudinal ligament. [79] (10.1186/s13018-025-05959-x)
• [L2] At 2 years, the present study showed that microdiscectomy was superior to nonoperative care for the treatment of chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation. [81] (10.2106/jbjs.21.00448)
• [L3] The modified classification has good reliability and its experience level of spine surgeons does not affect the reliability. [83] (10.1186/s13018-023-03688-7)
• [L4] In the short term, patients with > 50% IAP defects show no difference in lumbar stability or clinical outcomes compared to those with ≤ 50% defects, though complete IAP loss remains a concern for long-term instability. [84] (10.1186/s12891-025-09004-0)
• [L4] [85] (10.1002/jor.1100050206)
• [L3] In addition, old age, severe grade of surgical-level disc degeneration and more disc degeneration levels significantly increased the incidence of complications. [86] (10.1186/s12891-021-04940-z)
• [Paper] [87] (10.1186/s12891-026-10124-4)
• [L4] When multiple episodes of lumbar disc herniation occur in a patient's life span, PELD could be considered as an alternative good technique to treat LDH in each step by preserving normal anatomic structures. [88] (10.1186/s12891-017-1697-8)
• [L3] PEID and PETD have similar clinical efficacy in treating L5–S1 disc herniation. [109] (10.1186/s13018-024-04543-z)
• [L4] Malignant tumours involving the sciatic nerve are easily misdiagnosed as lumbar disc herniation due to similar clinical manifestations and low incidence. [111] (10.1186/s12891-021-04728-1)
• [L3] PEID has reliable efficacy and safety for treating highly downward-migrated disc herniation, and its long-term efficacy is comparable to PLIF. [114] (10.1186/s13018-023-04090-z)
• [L3] PTED has comparable efficacy in treating upper lumbar disc herniation as it does in treating lower lumbar disc herniation, and it is a safe and effective treatment method for upper lumbar disc herniation. [117] (10.1186/s12891-024-07588-7)
• [L4] Percutaneous endoscopic lumbar discectomy is a safe and efficacious technique to relieve symptoms of herniated discs and this improvement in back pain and leg symptoms translates to improvement in quality of life. [121] (10.1186/1749-799x-4-20)
• [L1] Due to its efficacy and safety, the procedure is recommended in treating single level lumbar HNP. [123] (10.1186/s12891-023-06429-3)
• [L3] In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. [127] (10.1186/s12891-020-03590-x)
• [L3] The device is efficient and safe for PTED in treating lumbar disc herniation at the L5–S1 level. [129] (10.1186/s13018-021-02533-z)
• [L3] [130] (10.1186/s12891-017-1522-4)
• [L3] PTES is an effective and safe method to treat calcified lumbar disc herniation. [133] (10.1186/s12891-020-03938-3)
• [L3] Gluteal pain is related to low lumbar disc hernia, with the L4/5 level being the main level responsible. [134] (10.1186/s12891-016-1204-7)
• [L3] Abnormal mechanical stress may contribute to this degeneration, highlighting the importance of managing stress in kyphotic deformities. [140] (10.1186/s12891-024-08157-8)
• [L3] Application of UBE for treatment of lumbar disc herniation yielded similar clinical outcomes to PELD, including pain control and patient satisfaction. [144] (10.1186/s13018-022-02929-5)
• [Paper] Transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation is a safe and effective procedure. [146] (10.1055/s-0031-1287774)
• [L4] The clinical effect of the UBE technique in treating upper lumbar disc herniation was reliable. [149] (10.1186/s12891-024-07339-8)
• [L3] Transforaminal endoscopic lumbar discectomy was effective and safe procedures in the treatment of disc herniation with leg pain and numbness. [150] (10.1186/s12891-020-03302-5)
• [L4] Best classification results were observed applying texture analysis to the two lowest intervertebral discs (L4-L5 and L5-S1), with accuracy of 83%, specificity of 83%, sensitivity of 82%, negative predictive value of 94%, precision of 56%, and receiver operating characteristic area-under-curve of 0.91. [157] (10.1002/jor.24973)
• [L5] Experimental results show that both damage and strain rate have a significant effect on the mechanical behavior of the disc fracture. [159] (10.1186/s13018-023-04424-x)
• [L3] [160] (10.1186/s12891-020-03814-0)
• [L1] A positive MRI T2-weighted image of the lumbar disc with HIZ indicates disc degeneration and may be a specific indicator for the physical diagnosis of discogenic low back pain. [163] (10.1186/s13018-023-04187-5)
• [L1] [165] (10.1186/1471-2474-11-17)
• [L1] Large cohort studies and alternative statistical techniques may yield more accurate estimates of the effectiveness of lumbar diskectomy. [167] (10.5435/00124635-200810000-00002)
• [L3] The effect of dural tear on in-hospital morbidity, mortality, and healthcare burdens was more significant in lumbar spinal decompression than in lumbar discectomy. [170] (10.1007/s00402-013-1843-1)
• [L3] [175] (10.1097/corr.0000000000002001)
• [L2] It was concluded that a combination of non-surgical spinal decompression therapy with routine physical therapy is more effective, statistically and clinically, than routine physical therapy alone in terms of improving pain, lumbar range of motion, back muscle endurance, functional disability, and physical role domain of quality of life, in patients with lumbar radiculopathy, following 4 weeks of treatment. [181] (10.1186/s12891-022-05196-x)
• [L3] Using the 4-grade fat infiltration system to determine the level of fat infiltration in the paraspinal muscles is more effective in predicting lumbar disc herniation compared to the 3-grade system. [182] (10.1186/s13018-023-04247-w)
• [L4] Spinal musculature plays an important role in spinal sagittal imbalance in patients with LDH. [188] (10.1186/s12891-016-1164-y)
• [L3] The 4-grade fat infiltration system was seen to be more effective than the 3-grade fat infiltration system in the determination of the level of fat infiltration in the paraspinal muscles and the prediction of lumbar disc herniation. [189] (10.1186/s12891-022-05180-5)
• [L1] Intradiscal PRP injection can significantly alleviate long-term pain and dysfunction in LDH patients, and its efficacy is greater than that of the control treatment; however, further studies are needed to verify the long-term mechanism involved. [190] (10.1186/s13018-025-06025-2)
• [L5] We have successfully constructed rat models of different types of intervertebral disc herniation, including disc degeneration, bulging, central herniation, and lateral herniation, using the method of puncture of intervertebral discs. [193] (10.1186/s13018-025-05710-6)
• [L4] DTI is a potential tool for functional diagnosis of lumbar nerve damage. [195] (10.1302/0301-620x.98b3.36036)
• [L3] Ultrasound imaging can be considered as a useful tool to detect changes in the sciatic nerve due to disc herniation. [197] (10.1186/s12891-019-2814-7)
• [L5] [201] (10.1016/j.arthro.2023.10.032)
• [L3] Wedge-shaped vertebrae is an independent risk factor for upper lumbar disc herniation. [202] (10.1186/s13018-019-1314-7)
• [L3] Prior knowledge of lumbar MRI results may introduce bias into the pinprick sensory testing component of the physical examination for lumbar radiculopathy. [204] (10.1186/1471-2474-11-275)
• [L4] Despite the minimally invasiveness and high visualization capabilities of biportal endoscopy, patients who are diabetic, smoker, or contained disk herniation on MRI should be counseled for higher risk of recurrence. [209] (10.5435/jaaosglobal-d-25-00137)
• [L3] We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. [213] (10.1302/0301-620x.105b4.bjj-2022-0704.r1)

See Also

• Cauda equina syndrome
• Sciatica
• Low back pain
• Lumbar spinal stenosis
• Lumbar discectomy
• Cervical myelopathy

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